PACT and HF-How can we Optimize Care Delivery for our

Patients

Susan Kirsh MDConsultant for PACT!, Diabetes QUERI, Center

for Implementation Practice and Research Support

Louis Stokes Cleveland VAMC

Quality Enhancement

Research Initiative

Goals and Objectives

• Chronic disease care needs improvement

• Principles of PACT!• Examples of the

Chronic Care Model and PACT!

• Applying PACT! Principles to heart failures across VA

• Opportunities for collaboration

Veterans on average have 3 chronic conditions

3

4

Poor Care Coordination Leads to Unnecessary Hospitalizations

0 718

36

62

95

131

169

219236

261

0

50

100

150

200

250

300

0 1 2 3 4 5 6 7 8 9 10+

Number of Chronic Conditions

Hos

pita

lizai

tons

for

Am

bula

tory

C

are

Sens

itiv

e C

ondi

tion

s P

er

1000

Med

icar

e B

enef

icia

ries

A

ges

65+

Source: Medicare Standard Analytic File, 1999.

5

Failures in chronic disease quality

• Guidelines translate poorly into practice

• Measures not adequate• Underuse of information

management and decision support tools

• Resistance to change, even in the face of demonstrable failures

• Hard to influence public policy

Barriers to Effective Chronic Disease Management

• Rushed practitioners not following established practice guidelines (according to surveys)

• Lack of care coordination • Lack of active follow-up to ensure the

best outcomes • Patients inadequately trained to

manage their illnesses

Sub Optimal Functional and Clinical Outcomes

UnpreparedPractice

Team

Uninformed,Passive Patient

FrustratingProblem-Centered

Interactions

Usual Care ModelUsual Care Model

improving chronic illness care

PatientPatient

PCPCProviderProvider

Ho

sp

ita

lists

No

n-V

A C

are

Current Current Primary Care Primary Care

ModelModel

Chronic Care Model as a Solution/Recipe

The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high quality chronic illness care

There are six fundamental elements “pillars of care” of the Chronic Care Model

Evidence-based change concepts under each element

Source: http://www.improvingchroniccare.org9

10

Joint Principles of the Joint Principles of the Patient-Centered Medical Home Patient-Centered Medical Home

TenetsTenets“Replaces episodic care based on illness and patient complaintswith coordinated care and a long‐term healing relationship” in

outpatient setting

• Ongoing relationship with personal physician or team-continuity

• Physician directed medical practice-or Primary Care Provider• Whole person orientation-Patient preferences • Enhanced access to care-appointments/services/information • Coordinated care across the health system-team care • Quality and safety-performance measures, registries

http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

PCMH/PACT!What it is; what it is not

• It is a series of attributes – some are very clear; some less so

• It is not a specific structure; the specific form will follow function, but is dependent on context

• It is the model the VA has chosen• It is not carte blanche to gain resources

The chronic care model with PCMH (Patient Aligned Care

Team)

80 78 78 74 78 84 80

15 17 18 20 16 12 15

0

25

50

75

100

AUS CAN GER NETH NZ UK US

Somewhat important

Very important

Percent saying very or somewhat important

Adults Across Countries Place High Value on Having aAdults Across Countries Place High Value on Having a“Medical Home”—Accessible, Personal, Coordinated Care“Medical Home”—Accessible, Personal, Coordinated Care

When you need care, how important is it that you have one practice/clinic where doctors and nurses know you, provide and coordinate the care that you need?

Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

Medical Home Increases Medical Home Increases Odds of Getting Preventive Odds of Getting Preventive

CareCare1

0.9

0.69

0.340.26

RegularSource All

Care

RegularSource

PreventiveCare

DifferentSource Ill and

Well Care

RegularSource Ill Care

No RegularSource

Ryan, Riley, Kang & Starfield, 2001

Odds Ratio

15

Current PACT! initiatives

• Demonstration labs• IHI style improvement or learning sessions-6-

share information• Teamlet training• Tool development in CPRS

– Primary care almanac, decision support, risk tools

• Additional staff– nurse care coordinators– health promotion disease prevention staff

• National evaluation-ACP biopsy

Learning Sessions Focus on Pillars

• Enhanced access to care– Telephone clinics, CCHT (telehealth), my

health e vet, secure text messaging, huddles for daily open slots

• Coordinated care across the health system– TEAMS and populations-Shared medical

appointments, nurse and pharmacy planned care, nurse protocols, innovation for homeless, mental health, CKD, service agreements with specialists

Attributes in Primary Care

• Quality and Safety– Performance measures, next available

appointment, post-hospitalization follow up, medication reconciliation

• Whole person orientation– Patient preferences, shared decision making,

patient understands the disease process, realizes his/her role as the daily self manager, family and caregivers engaged, provider is a guide on the side

HF Clinic as a Medical Home

• Class III/IV HF-Cardiology is their home?• Principles can be applied to enhance care

delivery– Improve Access: Telephone clinics, CCHT,

telehealth consultation Cardiologists– Care Coordination: HF SMAs-MANUAL, NP

or Pharmacists following sickest patients with registries, close post-hospitalization clinics, electronic reminders to patients for labs, follow up appointments

Opportunities for Collaboration

• Go to staff • Shared templates• Service

agreements• Hospital discharge

coordination• Other suggestion-

we need sharing of best practices!